Microvascular cutaneous flap for treatment of complications of black esophagus and complex esophageal reconstruction.

Central MessageThere is a demonstrable role for microvascular cutaneous free flaps in treatment of complications of black esophagus and in complex esophageal reconstruction. There is a demonstrable role for microvascular cutaneous free flaps in treatment of complications of black esophagus and in complex esophageal reconstruction. Primary repair of esophageal perforation often requires reinforcement with an intercostal muscle flap, pericardial fat pad, pleural patch (Grillo patch), or omental flap.1Cooke D.T. Lau C.L. Primary repair of esophageal perforation.Oper Tech Thorac Cardiovasc Surg. 2008; 13: P126-P137https://doi.org/10.1053/j.optechstcvs.2008.05.002Abstract Full Text Full Text PDF Scopus (5) Google Scholar Other flaps used to repair esophageal perforation have included anterolateral thigh (ALT), osteomuscular fibula, radial forearm, and pedicled pectoralis flaps.2Hanwright P.J. Purnell C.A. Dumanian G.A. Flap reconstruction for esophageal perforation complicating anterior cervical spinal fusion: an 18-year experience.Plast Reconst Surg Glob Open. 2015; 3e400https://doi.org/10.1097/GOX.0000000000000350Crossref PubMed Scopus (20) Google Scholar, 3Poelsler L. Koch O. Gaggl A. Presl J. Hutter J. Brandtner C. et al.Microvascular myocutaneous and cutaneous free flap reconstruction in patients with terminal esophagostomy after complicated oncological esophagus resection.Eur Surg. 2022; 54: 201-206https://doi.org/10.1007/s10353-021-00744-6Crossref Scopus (1) Google Scholar, 4Sokoya M. Vincent A. Cohn J.E. Kadakia S. Kohlert S. Ducic Y. Comparison of radial forearm free flap and gastric pull-up in pharyngo-oesophageal reconstruction.Clin Otolaryngol. 2019; 44: 405-407Crossref PubMed Scopus (3) Google Scholar In this mini case series, we present 2 unique cases that used microvascular cutaneous flaps for treatment of black esophagus and complex esophageal reconstruction. Written informed consent was obtained from both patients for the publication of this case report; institutional review board approval was not required. A 65-year-old male patient with history of atrial fibrillation, hypertension, type 2 diabetes, and alcohol use disorder presented with shortness of breath, hiccups, nausea, dysphagia, acute kidney injury, and weight loss. Esophagogastroduodenoscopy (EGD) revealed black esophagus, also known as acute esophageal necrosis (AEN).5Sheikh A.B. Mirza S. Abbas R. Javed N. Nguyen A. Hanif H. et al.Acute esophageal necrosis: an in-depth review of pathogenesis, diagnosis, and management.J Community Hosp Intern Med Perspect. 2022; 12: 96-103https://doi.org/10.55729/2000-9666.1020Crossref PubMed Google Scholar AEN is characterized by the circumferential black appearance of esophageal mucosa, likely resulting from ischemic insult and thromboembolic injury. He was managed nonoperatively with EGDs, acid suppression, nutrition, and resuscitation. However, the patient re-presented with epigastric pain and altered mental status. Imaging demonstrated air around the distal esophagus and active contrast extravasation into the right chest, concerning for esophageal perforation. EGD showed abnormal esophageal mucosa with fibrinous coating and transmural ischemia, and the perforation was greater than 1 cm at 37 cm from the incisors. He required emergent right thoracotomy, complete esophagectomy, and cervical esophagostomy. The patient recovered and returned months later for a substernal gastric interposition with left partial hemimanubrium, rib, and left clavicular head resection. His course was complicated by anastomotic leak and dehiscence requiring multiple wound debridements of the left neck and sternum, T-tube placement, and wound vac therapy. He later presented with a gastric conduit cutaneous fistula at the base of his neck near the left sternoclavicular joint. After multidisciplinary discussion with otolaryngology, and consideration given to gastric conduit resection, a decision was made to preserve the in situ conduit. Intraoperative EGD demonstrated a well-perfused gastric conduit with esophageal anastomosis located at 23 to 25 cm corresponding to his fistula site. The top half of the remaining sternum was resected in addition to bilateral sternoclavicular joints partially due to concern for osteomyelitis and to allow for adequate exposure to the gastric conduit defect (measuring 3 × 5 cm). Patch repair of the conduit was performed using a chimeric 2-paddled left ALT free flap (using the left transverse cervical artery and left external jugular vein as recipient vessels). One paddle was used to repair the gastric conduit and the other to repair the chest wall. He did well postoperatively, passed his barium swallow, had normal upper extremity function, and was discharged to the acute inpatient rehabilitation service on postoperative day 18 (Figure 1). The second case is a 59-year-old male patient with history of hypertension, gastroesophageal reflux disease, and Barrett's esophagus. Despite acid-suppression therapy, he required robotic paraesophageal hernia repair with Collis gastroplasty and Dor fundoplication. He had evidence of high-grade dysplasia on EGD, and his gastroenterologist felt endoscopic mucosal resection or radiofrequency ablation would be ineffective, given persistence of severe gastroesophageal reflux disease symptoms. Months later, he underwent transhiatal esophagectomy, cervical esophagogastric anastomosis, and pyloromyotomy with feeding jejunostomy placement. His course was complicated by anastomotic leak treated with open neck drainage and biweekly esophageal dilations for recurrent strictures. During a joint case with thoracic surgery and otolaryngology, the esophageal anastomotic stricture was noted at 22 to 25 cm on EGD and coincided with the level of the manubrium. A manubrial split was performed to allow appropriate free flap positioning. After exposing the stricture, a 6-cm esophagotomy was performed. A 3 × 6-cm radial forearm free flap was used to interpose into the esophagotomy to increase conduit diameter. The skin paddle was inset into the conduit, and surrounding fascia from the flap was used to reinforce closure. The transverse cervical artery and vein were used for revascularization. The patient did well postoperatively, passed his barium swallow, and was discharged home on postoperative day 15. Complex and unusual esophageal pathologies such as AEN are formidable surgical challenges that can result in difficult complications that require multidisciplinary approaches for management. Head and neck microvascular and reconstructive surgeons have a rich toolbox of options, often using free tissue transfer, for leaks, strictures, and even rare clinical entities such as black esophagus. In Case 1, chimeric ALT flap was optimal, as we needed multiple skin paddles. For Case 2, a thin, pliable flap was needed to fit in a tight space with a long pedicle making the radial forearm flap ideal. As demonstrated in these challenging cases, there is a demonstrable role for free tissue transfer in complex esophageal reconstruction.